Coding for Pediatric Preventive Care 2023: Essential CPT and Modifier Updates

Accurate medical coding is the backbone of efficient billing practices, especially in pediatric preventive care. Using outdated or incorrect codes can lead to claim denials and lost revenue for your practice. Staying informed about the latest updates is crucial for ensuring timely reimbursements and maintaining a healthy revenue cycle. This guide outlines the essential CPT codes and modifiers for pediatric preventive care in 2023, helping your practice navigate the coding landscape with confidence.

2023 CPT Codes for Pediatric Preventive Care

The Current Procedural Terminology (CPT) codes are used to report medical services and procedures. For pediatric preventive care in 2023, the following codes are essential for both new and established patients:

New Patient Preventive Care:

99381 – Infant (younger than 1 year): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient. This code is for preventive care visits for infants under one year old who are new to the practice.
99382 – Early Childhood (1-4 years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient. Use this code for new patients aged 1 to 4 years during their preventive care visits.
99383 – Late Childhood (5-11 years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient. This code applies to new patients in the 5 to 11 year age range for preventive care services.
99384 – Adolescent (12-17 years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient. For new patients between 12 and 17 years old receiving preventive care, use code 99384.
99385 – Young Adult (18+ years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient. While primarily focused on pediatrics, this code is listed as it completes the range and may be relevant in some pediatric-adjacent contexts for new patients 18 years and older.

Established Patient Preventive Care:

99391 – Infant (younger than 1 year): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient. For infants under one year old who are established patients, use code 99391 for preventive care visits.
99392 – Early Childhood (1-4 years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient. Established patients aged 1 to 4 years should be coded with 99392 for their routine preventive care.
99393 – Late Childhood (5-11 years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient. Code 99393 is designated for established patients aged 5 to 11 years receiving preventive care.
99394 – Adolescent (12-17 years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient. For established patients between 12 and 17 years old during preventive care visits, use code 99394.
99395 – Young Adult (18+ years): Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient. Similar to the new patient code, while primarily focused on pediatrics, this code completes the range for established patients 18 years and older.

Counseling and Risk Reduction Codes:

Pediatric preventive care often involves counseling and risk reduction strategies. Here are the relevant time-based codes:

99401 – Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes. Use this code for brief counseling sessions of around 15 minutes.
99402 – Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes. For counseling sessions lasting approximately 30 minutes, code 99402 is appropriate.
99403 – Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes. Use 99403 for longer individual counseling sessions of about 45 minutes.
99404 – Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes. For extended counseling sessions around 60 minutes, use code 99404.
99411 – Preventative medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes. This code is for group counseling sessions lasting about 30 minutes.
99412 – Preventative medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes. For longer group counseling sessions of approximately 60 minutes, use code 99412.

Other Relevant Codes:

99211 – Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. This code can be used for minor office visits that do not require a physician’s direct involvement.
99491 – Chronic care management services, at least 30 minutes of physician or other qualified health care professional time, per calendar month. For chronic care management, use code 99491 for the first 30 minutes of service.
99437 – Chronic care management services, each additional 30 minutes of physician or other qualified health care professional time, per calendar month (List separately in addition to code for primary procedure). Use 99437 for each additional 30 minutes of chronic care management beyond the initial 30 minutes.
99487 – Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, functional decline or permanent loss of function; establishment or substantial revision of care plan; moderate or high intensity level decision making; 60 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. For complex chronic care management, use code 99487 for the first 60 minutes of clinical staff time.
99489 – Complex chronic care management services, each additional 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). Code 99489 is used for each additional 30 minutes of complex chronic care management beyond the initial 60 minutes.
99424 – Principal care management services, for a single high-risk disease, at least 30 minutes of physician or other qualified health care professional time per calendar month. Use 99424 for principal care management for a single high-risk disease for the first 30 minutes.
99425 – Principal care management services, for a single high-risk disease, each additional 30 minutes physician or other qualified health care professional time per calendar month (List separately in addition to code for primary procedure). Use code 99425 for each additional 30 minutes of principal care management beyond the initial 30 minutes.
99426 – Principal care management services, for a single high-risk disease, at least 20 minutes of clinical staff time directed by physician or other qualified health care professional per calendar month. For principal care management with clinical staff time, use 99426 for the first 20 minutes.
99427 – Principal care management services, for a single high-risk disease, each additional 20 minutes clinical staff time directed by physician or other qualified health care professional per calendar month (List separately in addition to code for primary procedure). Code 99427 is used for each additional 20 minutes of clinical staff time for principal care management beyond the initial 20 minutes.

Key Pediatric CPT Modifiers for 2023

Modifiers provide additional information about the services provided without changing the CPT code itself. Here are essential modifiers for pediatric preventive care in 2023:

Z00.110 – Health supervision of newborn under 8 days old. Use this modifier for health supervision visits for newborns under 8 days old.
Z00.111 – Health supervision of newborn 8 to 28 days old. For health supervision visits for newborns between 8 and 28 days old, use modifier Z00.111.
Z00.121 – Routine child health examination with abnormal findings. This modifier is used when a routine health exam for a child reveals abnormal findings.
Z00.129 – Routine child health examination without abnormal findings. Use this modifier for routine child health exams where no abnormal findings are present.
Z00.00 – Routine adult health examination without abnormal findings. While less common in pediatric specific coding, this is for routine adult health exams without abnormal findings and included for context.
Z00.01 – Routine adult health examination with abnormal findings. Similar to above, this is for routine adult health exams with abnormal findings and included for context.
Z28.3 – Underimmunization status. Use this modifier to indicate a patient’s underimmunization status.
Z71.3 – Dietary counseling and surveillance. For visits that include dietary counseling, use modifier Z71.3.
Z71.82 – Exercise counseling. Modifier Z71.82 is for encounters that involve exercise counseling.
Z71.84 – Health counseling for travel. Use Z71.84 when health counseling is provided for travel purposes.
Z71.85 – Immunization safety counseling. For counseling related to immunization safety, use modifier Z71.85.
Z71.89 – Other specified counseling. This modifier is for other specific types of counseling not listed under other Z71 codes.
Z71.9 – Counseling, unspecified. Use Z71.9 for counseling services when the specific type of counseling is not specified.

Staying updated with the latest coding guidelines is essential for the financial health of your pediatric practice. Accurate coding ensures proper reimbursement, reduces claim denials, and streamlines your billing process. For further assistance with pediatric medical billing and coding, consider partnering with a professional medical billing team.

Disclaimer: This information is for informational purposes only and should not be considered as professional medical billing advice. Always consult official coding resources and professional guidance for specific coding needs.